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BOEHRINGER INGELHEIM REFERRAL FORMPlease complete and fax this form to 1-866-867-1861 Contact BI Solutions Plus: 1-844-8-SOLUTION (1-844-876-5884), Monday – Friday, 8:00 am – 8:00 pm, ET.PRESCRIBER INFORMATION (Verification of Benefits will be faxed to this Prescriber)
NAME (First, MI, Last):
PRESCRIBER'S NAME (FIRST, LAST):
MEDICAID/MEDICARE PROVIDER#
DOB (MM/DD/YYYY):
BENEFIT INVESTIGATION FOR:INSURANCE INFORMATION (Complete this section or provide a copy of insurance card)DIAGNOSIS FOR WHICH THIS MEDICATION IS BEING PROCESSED:
o STIOLTO RESPIMAT
o SPIRIVA HANDIHALER
POLICY HOLDER NAME
SPIRIVA RESPIMAT 1.25 mcg/actuation
o COMBIVENT RESPIMAT
RELATIONSHIP TO CARDHOLDER
POLICY HOLDER DOB
SPIRIVA RESPIMAT 2.5 mcg/actuation
DATE OF DIAGNOSIS: o Male o Female ICD-10:
PAYER/PLAN PHONE#
DRUG PRESCRIPTION: MEDICATION NAME:
o NEW TO MEDICATION o RESTART o CONTINUING (START DATE)
QUANTITY: REFILLS:
POLICY HOLDER NAME
BENEFIT INVESTIGATION FOR:
RELATIONSHIP TO CARDHOLDER
POLICY HOLDER DOB
DIAGNOSIS FOR WHICH THIS MEDICATION IS BEING PROCESSED:
PAYER/PLAN PHONE#
o PRADAXA 75 mg o PRADAXA 110 mg o PRADAXA 150 mg
DATE OF DIAGNOSIS: o Male o Female ICD-10:DRUG PRESCRIPTION: MEDICATION NAME:
o NEW TO MEDICATION o RESTART o CONTINUING (START DATE)
CARD/BIN# (Please include alpha prefix/suffix with policy, group and/or PCN #'s when applicable)
Prior AuthorizationIf you would like Solutions Plus by Boehringer Ingelheim to provide support for the prior authorization process, please check the applicable box(es) below:Prior Authorization Form Assistance By checking this box, I request that Solutions Plus by Boehringer Ingelheim assist my office in determining the requirements of this patient's health plan relating to prior authorization
for the medication(s) specified above. I understand that such assistance includes procurement of the health plan-specific prior authorization form, and completion of the insurance and patient and provider demographic information sections thereon based on information provided by my office on this referral form. I understand that any partially completed prior authorization forms will be provided by Solutions Plus by Boehringer Ingelheim and that completion and submission of the form to the above named patient's health plan is the responsibility and in the discretion of my office.
Prior Authorization Monitoring Status I hereby request and authorize Solutions Plus by Boehringer Ingelheim to monitor status of the prior authorization submissions for the above named patient and to provide status
updates to my office with respect to this patient's prior authorization for treatment with the specified medication(s).FOR STATES REQUIRING HANDWRITTEN EXPRESSIONS FOR PRODUCT SELECTION, USE THIS AREA (e.g., medically necessary, may not substitute, dispense as written, etc.)Physician CertificationI verify that the patient and physician information contained in this enrollment form is complete and accurate to the best of my knowledge and that I have prescribed the products identified on this form based on my professional judgment of medical necessity. I authorize Boehringer Ingelheim Pharmaceuticals, Inc. ("Boehringer Ingelheim"), its affiliated companies, vendors, agents, and representatives (collectively, "Solutions Plus by Boehringer Ingelheim") to perform a preliminary assessment of insurance verification for the above-named patient. If my patient is eligible to receive free product under Boehringer Ingelheim's Patient Assistance Program (PAP), I certify and agree that neither I nor anyone on my behalf shall submit a claim to any third-party payer for payment of product provided under that program. I warrant that any product provided to me under the Boehringer Ingelheim PAP will be provided only to the approved patient and will not be sold, traded, or returned for credit.I further confirm that I understand that insurance verification and other information provided by Solutions Plus by Boehringer Ingelheim in any patient access support program are provided as a service to patients and that Solutions Plus by Boehringer Ingelheim makes no representation or guarantee that any insurance reimbursement or other payment for the BI Products I prescribe will be available. I also understand Solutions Plus by Boehringer Ingelheim makes no representations or warranties, expressed or implied, about the accuracy of the information and that Solutions Plus by Boehringer Ingelheim is not liable for any damages resulting from or relating to the Solutions Plus program services.Prescriber Signature: (Required to validate prescriptions)
Dispense as written / Do not substitute
Substitution permitted / Brand exchange permitted Date
The undersigned further certifies that I have obtained all necessary authorizations and approvals, if any, required by law or regulation to have been obtained from the above named patient to permit the sharing of Health Information with Solutions Plus by Boehringer Ingelheim. I also confirm that I will if required by law or regulation execute a Business Associate Agreement ("BAA") with Boehringer Ingelheim's vendor for patient access support services. A form BAA has been provided to me.Prescriber Signature:
Patient Representative Signature
Please see accompanying full Prescribing Information and Instructions for Use for Spiriva® Respimat® (tiotropium bromide) Inhalation Spray, Combivent® Respimat® (ipratropium bromide & albuterol).Please see accompanying full Prescribing Information for StioltoTM Respimat® (tiotropium bromide and olodaterol) Inhalation Spray,including Boxed Warning, Medication Guide, and Instructions for Use.Please see accompanying full Prescribing Information for Pradaxa® (dabigatran etexilate mesylate) Capsules including Boxed Warning.
The information contained in this communication is confidential and intended for the addressee. It may contain protected health information (PHI) under HIPAA. PHI is personal and sensitive information related to a person's health. This information is sent to you under circumstances when a participant's authorization is not required. You, the recipient, are obligated to maintain it in a safe, secure, and confidential manner. Redisclosure, unless permitted by law, is prohibited. If you are not the intended recipient, you are hereby notified that dissemination, disclosure, copying, or distribution of this information is strictly prohibited and may be unlawful. Please notify sender immediately to arrange for return of this document.
Copyright 2016 Boehringer Ingelheim Pharmaceuticals, Inc. Al rights reserved. [2/16] PC-MULT-0053-PROF